A Conversation with Jo Anne Rainville
Jo Anne Rainville, Executive Director
Interview by Elizabeth Harvey
The Tamworth Community Nurse Association is a nonprofit organization in the rural town of Tamworth, New Hampshire. It provides residents free health services, such as dressing changes, medical equipment loans, and flu clinics. TCNA provides local care that may otherwise require an expensive hospital visit, as well as care typically not covered by insurance. I recently sat down with Jo Anne Rainville, a nurse and the Executive Director of TCNA, to discuss the organization, its impact, and its potential for replication elsewhere.
NPi: Tell me about the Tamworth Community Nurse Association and how it began.
JR: It was founded in 1921 by Elizabeth Lane Whittemore, a visionary woman whom I wish so much I could meet and have a conversation with. She was a woman who clearly thought out of the box. The Tamworth-Chocorua area in the ‘20s, ‘30s, and probably to some extent ‘40s, was a place where people would come up from Providence, New Haven, Boston, and New York to escape the heat of the city. Quite a group would come up: Henry and William James (their home is still here), Julia Ward Howe, E.E. Cummings, Elizabeth Cady Stanton—people who were looking at societal changes and thinking about different ways to impact and relate to the community. Amongst them was Elizabeth Lane Whittemore, who was associated with the New Haven visiting nurses.
Even now, it can take an hour to get from Tamworth to Memorial Hospital in North Conway on a busy day in the summer. Going to Huggins in Wolfeboro can get bogged down with traffic. It’s a forty minute ride at best. So here we sat in the middle of the county, and Elizabeth Lane Whittemore believed Tamworth could benefit from a visiting nurse association. She requested the help of some of her friends, and at first they decided they would subcontract to a Red Cross nurse who would come up and work here during the summer. The nurse did a lot of looking after the children’s health in town, but little by little that expanded. The original place where she worked was the school that is now the Unitarian Universalist Church up at the corner… She traveled by horse and buggy to the different areas of Tamworth.
The Tamworth Community Nurse Association began so that no one in the town of Tamworth would go without health care, either because they didn’t have access to it, the hospitals were far away, or they couldn’t afford it. To this day the Tamworth Community Nurse Association has no fee for the services we offer.
NPi: What services do you provide the Tamworth community?
JR: We provide skilled nursing services, so anything from dressing changes and medication setups to evaluations of disease processes and interventions at the hospital… We also have a role in the public health of the community as a whole. Two years ago we had to deal with uranium and arsenic pollution of our downtown water supply. We also had a tire dump in town. The selectmen were working hard with the EPA to try to get it removed. We got involved with the Department of Public Health and asked them to help because of the threat of Triple E [Eastern Equine Encephalitis virus]. With our efforts and those of the selectmen, we were able to get rid of the tire dump. So it’s more than taking a person’s blood pressure or doing a dressing; it’s looking after the health of the entire town.
NPi: How are these services paid for?
JR: We get our income three different ways. In her will, Mrs. Whittemore left us half of her estate, and that started the endowment for the Tamworth Community Nurse Association. The endowment today sits at about $1.1 million. Ideally it would be $3 million, and that’s one of the things we’re working on. We got it up to $1.5 million, and then we had the current economic collapse and lost about $400K, which is about average compared to what other endowments lost… Recently we had our town meeting, and once again the town voted to support us with another $40K… We do appeal letters, fundraisers, grant writing. $60K is a lot of money for us to raise year after year. So getting that endowment up is key.
Mrs. Whittemore’s efforts basically took care of the first 100 years. I believe strongly, as Executive Director of this organization, as a taxpayer in this town, and as a person who lives here, that we have a moral responsibility to ensure the next 100 years. It would be our absolute pleasure to be able to look at the town and say, “Thank you very much, we are not going to need your generosity of $40K this year. We have increased our endowment to where it can [sustain our operations].” If we get the endowment to a place where it can support the day-to-day running of the organization, we can then look at different special projects to take on and do even more than we’re doing now.
NPi: What kind of an impact do you have on the community?
JR: This organization is much, much loved by the people of this town. As far as we know, we’re the only organization like this in the United States. If there is another one, I would love to have someone contact me. One is the loneliest number. The people of this town are utilizing us more and more. I’m the full-time nurse director. I have another nurse that works with us 16 hours per week, and a very part-time nurse who also comes in a few hours a week. We are lucky to have Dave as our administrative assistant. We’re a small staff, and out of that small staff, we make approximately 7,000 and change nursing visits, consults, and interventions each year. We also coordinate the delivery of meals-on-wheels through this office. Last year we delivered close to 12,000 meals. Realize Tamworth’s population is 2,500. This is a lot of contact that we have with the townspeople.
NPi: What are some of the obstacles and challenges the organization is facing?
JR: Probably the biggest obstacles and challenges all come from funding. If we could recoup the number of hours we have to spend in grant writing, fundraisers, letter-writing, and our annual and holiday appeals, we’d have an awful lot more time to be doing other things here in Tamworth. We run a very lean machine, and we think hard and long before we spend any money… I would say that if the day came that we suddenly had a $3 million endowment, I would be a very happy woman knowing that I could focus my energy on other issues.
NPi: What have you learned from doing this work, personally and as an organization?
JR: I have learned to see health in the broadest manner which you can interpret it. Health is not just a person’s blood pressure or medications, their wound. This organization gives us the ability to treat a person holistically—to ask ourselves and the individual what’s holding them back from living at their optimal level of health and life experience. Then we are able to look at what we can do to remove those obstacles. That is a truly refreshing way to practice nursing.
NPi: What is your approach to health care? You mentioned a holistic approach, but can you share more details, and speak about how you may differ from other nursing organizations?
JR: The way most community home care is set up is through the Medicare and Medicaid standards. Whether or not you receive Medicare, it is still Medicare that is the “certifying entity” that says that you can bill an insurance company and be reimbursed. For instance, I have Cigna health care. If I needed services from a visiting nurse association (VNA)—that VNA, in order for Cigna to pay it for the services they would give me, would have to be certified. And like I say, “certified” means Medicare or Medicaid sets up the rules. They say these are the criteria to which you have to fall into in order to receive services. We don’t have those kind of criteria… A person has to be referred by a physician in the VNA model. With our model I can have a person walk in here and say, “I saw Suzie down at the grocery store and she looked ghastly. You really ought to go check on her.” That allows me to turn around and, say, the next time I’m driving by Suzie’s house, just go knock at the door and say, “Hi Suzie, I just wanted to drop in and see how you’re doing.” Was she just having a bad day? That happens. Or was there really something going on, and she’s struggling? Once that’s determined, I can determine a course of action and [potential] interventions.
Just how we begin interacting with people is based on friendship, community, caring for one another. People can call me up and say, “I don’t feel so good today,” or “I fell and I sprained my ankle yesterday,” this or that. They can come into the office and see us, or we can go to them. In the VNA setting, it’s always the nurse going to the home. Our people don’t have to be homebound.
NPi: Is there a service that your organization doesn’t provide that you’d like to be able to provide?
JR: Ideally, I’d like to see us do more with preventive care. I’d like to see us be able to provide for women getting mammograms, pap smears, and screenings. We have a big void with a large uninsured group of Americans. I would like to see more men come have their blood drawn and have a PSA [a hormone associated with prostate cancer] checked. Many illnesses get totally out of control because people don’t have access to preventive care.
In Tamworth, the people of this town are both my patients and my neighbors, my friends. A few years ago, I had a woman who was my age diagnosed with stage four colon cancer. She hadn’t been able to afford a colonoscopy despite the fact that colon cancer ran in her family, and we helped her to die at home. She didn’t have to die. If we had the funds ourselves, the first thing I would do is set up a good neighbor fund so we could save lives. That would be the biggest thing I’d like to see us do.
I’d also like to see us have a wheelchair van. I’ve got a patient who needs to be picked up from his home in Chocorua and taken to Memorial Hospital for routine doctor appointments. It costs $800 round-trip for the wheelchair van, and it’s not even 30 miles. [Having a wheelchair van] would also improve people’s quality of life. They could go to Barnstormer’s Theater, get out of the house, not be a shut-in. These kinds of things. I would like to see us have some lab equipment so we’re [doing more than just] drawing blood, and patients could walk out with their test results… I have a lot dreams if we had the resources to make it happen.
NPi: How have people reacted to your unique approach to health care? Have people changed their opinions about how healthcare organizations should operate?
JR: We believe that the Tamworth Community Nurse Association can be a model for rural healthcare. We were fortunate enough to be featured on National Public Radio, which was very exciting. We got calls from Alaska, California, Florida, Detroit, Massachusetts, all over the United States… We’ve had people come to visit and find out how they can start an organization like ours in their town… We have done some work in trying to crunch the numbers that we save in insurance dollars and personal dollars. We believe we come out somewhere near the million dollar mark annually here in Tamworth. We [help people] avoid trips to the emergency room when it’s something we can take care of right here.
There are so many different ways we can impact society and save real dollars for you, me, health insurance companies… We can offer people convenience and one-on-one care. People walk in here and we know them. We’ve known them for a long time… It’s a much deeper relationship than a purely clinical one. I want to be clear that I’m in no way trying to speak with disrespect towards the VNAs or the system that we have. All we’re trying to offer is a different way to do it.
NPi: Do you think other towns might be able to take this up, that it’s workable beyond Tamworth?
JR: This is totally replicable. This could be in every rural town, not just in New Hampshire. And $160K per year (our budget this year) is pretty short money when you look at what we are saving the system, the relationships we have, and the care we can give a community. That’s a huge impact for a small seed of an idea. Ideally, we could take Mrs. Whittemore’s wonderful idea about bringing this to Tamworth and have it spread throughout rural America, but it takes getting known. I’m not looking to franchise this company. That’s the last thing we want. We want to continue doing what we do. But we feel we do it well and that we’ve got a real gem that can be shared throughout the country. I want every governor to know about the Tamworth Community Nurse Association, to take a pencil and crunch those dollars, and stop and look at what it would cost to set it up… It’s totally replicable.
NPi: What types of organizations might you like to collaborate with?
JR: Organizations that could give the uninsured access to health care. I’ve got great hopes for healthcare reform… I’d like something that would make this healthcare system accessible to everyone. If there are people doing work [in this area], I would love to be part of that collaboration.
A few years ago, I got a call from a vice president over at Huggins Hospital. She said she had been talking to the selectmen about what Huggins could do for the people in Tamworth and was told to call me. She asked me, “What can we do to help you do your job?” That is so unusual in this day and age. I’ve never had a hospital call me up and ask me that. They run a very good program called the Community Benefits Program that works with New Hampshire Health Access. We were able to get dozens and dozens of individuals and families in town signed up on the Community Benefits Program, which at least allows them to have a health care provider and fall into a sliding scale so that they’re not necessarily paying 100% of the cost of that mammogram, for example. It’s collaborations like that that can help us open doors and make care accessible. This means that when I look at someone and say, “When was the last time you had a colonoscopy, a mammogram, a PSA test or whatever,” the answer won’t be, “Five years ago. I couldn’t afford it. I can’t get there.”
NPi: What is a lesson you would pass on to other leaders, other people looking to get involved in the community in a similar way?
JR: Think outside of the box… Don’t get bogged down with dealing with what [already] is. Be able to have the vision and foresight to think about what can be, what would make things better. What gets in people’s way? What’s stopping someone from being the best person they can be? What’s stopping me from being as effective as I can be? And then taking on the challenge of answering those questions. And you’re going to tilt at some windmills. There are going to be people who say, “You’re never going to make that happen.” And maybe you won’t, but if you get one out of ten things that you think are good ideas rolling, maybe that’s enough.
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